Uninsured Motorist Complaint Form ○ ○ ○ ○ ○ ○ ○ Vehicle Owner’s Name- First Middle Last Street Address City State Zip Code Vehicle Tag Number Vehicle Year Make Vehicle Operator Insurance Company Policy Number Nature of Complaint 1. Accident Date Amount of Damages to your Property Personal Injuries Sustained? Police Report Number (Attach Copy) Officer’s Name Location ❒ yes ❒ no 2. Other (Specify date, location, and description of incident. Use other side if necessary) Company contacted regarding alleged uninsured motorist’s insurance information and results of contact. (Attach supporting correspondence from company contacted) Explain results of contact with alleged uninsured motorist Complainant Name (print)- First Middle Last Street Address City State Zip Code Signature Client Name (print) - First Middle Last Home Telephone Number Work Telephone Number Date Claim Number: ❒ Check here if notice of results is needed The Motor Vehicle Administration cannot assist in collection for damages sustained in a motor vehicle accident. If the vehicle in question is uninsured, suspension action may be taken against the owner’s driving and registration privileges in accordance with Maryland’s compulsory insurance laws. Mail completed form and, if available, copies of police reports and letters you received from insurance companies disclaiming coverage to: Motor Vehicle Administration, Insurance Compliance Division, 6601 Ritchie Highway N.E., Glen Burnie 21062; telephone (410) 768-7291, fax (410) 787-2953. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Alleged Uninsured Motorist’s Information ○ For more information, please call: 1-800-638-8347 (touch tone calls only), 1-800-950-1MVA (1682) (to speak to a customer service representative), From Out-of-State: 1-301-729-4550, TDD for the hearing impaired: 1-800-492-4575. Visit our website at: www.mva.state.md.us Motor Vehicle Administration 6601 Ritchie Highway N.E. Glen Burnie, Maryland 21062 ICD-034 (5-00) American LegalNet, Inc. www.FormsWorkFlow.com